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Endometriosis at 2nd surgery—residual or recurrent disease
LETTERS TO THE EDITOR Paul G. McDonough, M.D. Associate Editor Endometriosis at second surgery—residual or recurrent disease?
University of Genoa Genoa, Italy
To the Editor:
November 16, 2004
We read with great interest the recent article by Abbott et al. (1) examining the effect of laparoscopic excision of endometriosis on pain and quality of life. Based on our own experience, we totally agree with their findings; however, we would like to bring to your attention some aspects of the study, which may deserve further discussion. Among 16 patients who underwent radical excision of endometriosis, 3 (18.8%) were found to have revised American Fertility Society (rAFS) stage IV disease at the second laparoscopy after 6 months, and 1 of them had rAFS score 142. In our experience, this percentage and severity of recurrence (6 months after radical excision of endometriosis) is unexpectedly high and raises some concerns and questions. It is well known that stage IV endometriosis is typically associated with the presence of ovarian endometriotic cysts ⬍3 cm) or cul-de-sac obliteration. If ovarian cysts were observed at second surgery, it would be relevant to know how the cysts were removed at first laparoscopy. Importantly, the investigators previously reported the use of vaporization of ovarian endometriotic cysts (2), which may be associated with increased risk of recurrence when compared with the excision of the capsule (3). In addition, it would be interesting to know how the patients were investigated before the first laparoscopy (i.e., transvaginal ultrasonography) and whether this evaluation was performed in the month before surgery. We believe that this information may help in understanding whether the presence of endometriosis at second surgery was due to residual or recurrent disease. Finally, although they accurately described the exclusion criteria of the study, it remains unclear whether some of the patients (n ⫽ 52) included in the randomization had uterine fibroids. This comorbidity is particularly relevant considering that the presence of uterine fibroids has been associated with dyspareunia and noncyclic pelvic pain (4). In addition, their presence seems to be increased in women with endometriosis when compared with controls (5). Simone Ferrero, M.D. Pasquale Petrera, M.D. Valentino Remorgida, M.D. Nicola Ragni, M.D. Department of Obstetrics and Gynaecology San Martino Hospital 0015-0282/05/$30.00
REFERENCES 1. Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril 2004;82:878 – 84. 2. Garry R, Clayton R, Hawe J. The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. BJOG 2000;107:44 –54. 3. Vercellini P, Chapron C, De Giorgio O, Consonni D, Frontino G, Crosignani PG. Coagulation or excision of ovarian endometriomas? Am J Obstet Gynecol 2003;188:606 –10. 4. Lippman SA, Warner M, Samuels S, Olive D, Vercellini P, Eskenazi B. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertil Steril 2003;80:1488 –94. 5. Hemmings R, Rivard M, Olive DL, Poliquin-Fleury J, Gagne D, Hugo P, et al. Evaluation of risk factors associated with endometriosis. Fertil Steril 2004;81:1513–21.
doi:10.1016/j.fertnstert.2004.12.022
Reply of the Authors: We thank you for your interest in our article. We are happy to respond to the issues you raise. First, the finding of advanced disease in some patients at 6 months after their original excisional surgery seems perplexing but actually has given us significant insight into this disease. Clinical and video review shows that one patient with stage IV disease at her second (follow-up surgery) includes bilateral endometriomas and cul-de-sac obliteration. This is in contrast to mild disease at her first surgery and almost certainly represents new disease, as it is in separate anatomical locations. The observation of such rapid and severe recurrence of endometriosis indicates a possible cause as to why surgery is not always successful. For the remaining two cases we offer alternative explanations. In at least one case, we suspect that the woman had Cullen’s syndrome (1), with extensive cul-de-sac and posterior cervical disease. It is almost certain that the disease was not fully resected at first surgery—an impossibility because we performed conservative uterine-sparing surgery. It is likely that the focus of her disease was the posterior cervix and uterine wall and the rapid recurrence, including endometrioma formation, occurred secondary to this persistent disease. Finally it is certainly possible that recurrent endometrioma formation was due to surgical technique. Our technique is to
Fertility and Sterility姞 Vol. 83, No. 3, March 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
815
University of Genoa Genoa, Italy
To the Editor:
November 16, 2004
We read with great interest the recent article by Abbott et al. (1) examining the effect of laparoscopic excision of endometriosis on pain and quality of life. Based on our own experience, we totally agree with their findings; however, we would like to bring to your attention some aspects of the study, which may deserve further discussion. Among 16 patients who underwent radical excision of endometriosis, 3 (18.8%) were found to have revised American Fertility Society (rAFS) stage IV disease at the second laparoscopy after 6 months, and 1 of them had rAFS score 142. In our experience, this percentage and severity of recurrence (6 months after radical excision of endometriosis) is unexpectedly high and raises some concerns and questions. It is well known that stage IV endometriosis is typically associated with the presence of ovarian endometriotic cysts ⬍3 cm) or cul-de-sac obliteration. If ovarian cysts were observed at second surgery, it would be relevant to know how the cysts were removed at first laparoscopy. Importantly, the investigators previously reported the use of vaporization of ovarian endometriotic cysts (2), which may be associated with increased risk of recurrence when compared with the excision of the capsule (3). In addition, it would be interesting to know how the patients were investigated before the first laparoscopy (i.e., transvaginal ultrasonography) and whether this evaluation was performed in the month before surgery. We believe that this information may help in understanding whether the presence of endometriosis at second surgery was due to residual or recurrent disease. Finally, although they accurately described the exclusion criteria of the study, it remains unclear whether some of the patients (n ⫽ 52) included in the randomization had uterine fibroids. This comorbidity is particularly relevant considering that the presence of uterine fibroids has been associated with dyspareunia and noncyclic pelvic pain (4). In addition, their presence seems to be increased in women with endometriosis when compared with controls (5). Simone Ferrero, M.D. Pasquale Petrera, M.D. Valentino Remorgida, M.D. Nicola Ragni, M.D. Department of Obstetrics and Gynaecology San Martino Hospital 0015-0282/05/$30.00
REFERENCES 1. Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril 2004;82:878 – 84. 2. Garry R, Clayton R, Hawe J. The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. BJOG 2000;107:44 –54. 3. Vercellini P, Chapron C, De Giorgio O, Consonni D, Frontino G, Crosignani PG. Coagulation or excision of ovarian endometriomas? Am J Obstet Gynecol 2003;188:606 –10. 4. Lippman SA, Warner M, Samuels S, Olive D, Vercellini P, Eskenazi B. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertil Steril 2003;80:1488 –94. 5. Hemmings R, Rivard M, Olive DL, Poliquin-Fleury J, Gagne D, Hugo P, et al. Evaluation of risk factors associated with endometriosis. Fertil Steril 2004;81:1513–21.
doi:10.1016/j.fertnstert.2004.12.022
Reply of the Authors: We thank you for your interest in our article. We are happy to respond to the issues you raise. First, the finding of advanced disease in some patients at 6 months after their original excisional surgery seems perplexing but actually has given us significant insight into this disease. Clinical and video review shows that one patient with stage IV disease at her second (follow-up surgery) includes bilateral endometriomas and cul-de-sac obliteration. This is in contrast to mild disease at her first surgery and almost certainly represents new disease, as it is in separate anatomical locations. The observation of such rapid and severe recurrence of endometriosis indicates a possible cause as to why surgery is not always successful. For the remaining two cases we offer alternative explanations. In at least one case, we suspect that the woman had Cullen’s syndrome (1), with extensive cul-de-sac and posterior cervical disease. It is almost certain that the disease was not fully resected at first surgery—an impossibility because we performed conservative uterine-sparing surgery. It is likely that the focus of her disease was the posterior cervix and uterine wall and the rapid recurrence, including endometrioma formation, occurred secondary to this persistent disease. Finally it is certainly possible that recurrent endometrioma formation was due to surgical technique. Our technique is to
Fertility and Sterility姞 Vol. 83, No. 3, March 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
815